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ATLANTA — On a recent summer evening, Raymia Taylor wandered into a recreation center in a historical downtown neighborhood, the only enrollee to attend a nearly two-hour event for people who have signed up for Georgia’s experimental Medicaid expansion.

The state launched the program in July 2023, requiring participants to document that they’re working, studying, or doing other qualifying activities for 80 hours a month in exchange for health coverage. At the event, booths were set up to help people join the Marines or pursue a GED diploma.

Taylor, 20, already met the program’s requirements — she studies nursing and works at a fast-food restaurant. But she said it wasn’t clear what paperwork to submit or how to upload her documents. “I was struggling,” she said.

Georgia is the only state that requires certain Medicaid beneficiaries to work to get coverage. Republicans have long touted such programs, arguing they encourage participants to maintain employment. About 20 states have applied to enact Medicaid work requirements; 13 won approval under the Trump administration. The Biden administration has worked to block such initiatives.

The Georgia Pathways to Coverage program shows the hurdles ahead for states looking to follow its lead. Georgia’s GOP leaders have spent millions of dollars to launch Pathways. By July 29, nearly 4,500 people had enrolled, the state’s Medicaid agency told KFF Health News.

That’s well short of the state’s own goal of more than 25,000 in its first year, according to its application to the federal government, and a fraction of the 359,000 who might have been eligible had Georgia simply expanded Medicaid under the Affordable Care Act, as 40 other states did.

So far, the pricey endeavor has forced participants to navigate bureaucratic hurdles rather than support employment. The state would not confirm whether it could even verify if people in the program are working.

Research shows such red tape disproportionately affects Black and Hispanic people.

“The people that need access to health care coverage the most are going to struggle with that administrative burden because the process is so complicated,” said Leah Chan, director of health justice at the Georgia Budget and Policy Institute.

At an August press event, Georgia Republican Gov. Brian Kemp announced a $10.7 million ad campaign to boost enrollment in Pathways, one of his administration’s major health policy initiatives. The plan has cost more than $40 million in state and federal tax dollars through June, with nearly 80% going toward administration and consulting fees rather than paying for medical care, according to data the state Medicaid agency shared with KFF Health News.

Enrollment advisers, consumer advocates, and policy researchers largely blame a cumbersome enrollment process, complicated program design, and back-end technology flaws for Pathways’ flagging enrollment. They say that the online application is challenging to navigate and understand and lacks a way for people to receive immediate support, and that state staffers don’t respond to applicants in a timely manner.

“It’s just an administrative nightmare,” said Cynthia Gibson, director of the Georgia Legal Services Program’s Health Law Unit, who helps Pathways applicants appeal denials.

Administrative challenges have also undermined a key part of the program’s philosophy: that people maintain employment to keep coverage. As of July, the state was not removing enrollees for not meeting Pathways’ work requirement, according to Fiona Roberts, a spokesperson for Georgia’s Medicaid agency.

“We understand that people need to be held accountable to those 80 hours for the spirit of the program, and we intend to do that,” said Russel Carlson, the agency’s commissioner.

Pathways is set to expire Sept. 30, 2025, unless the state asks the Centers for Medicare andamp; Medicaid Services for an extension. Georgia officials say they won’t have to make that request until next spring, well after November’s election. So the state could be asking for an extension from the Trump administration, which approved the program in the first place.

Georgia officials sued the Biden administration this year to keep Pathways running without going through the official extension process, which requires the state to conduct public comment sessions, gather extensive financial data, and prove that Pathways has met its goals. A federal judge ruled against Georgia.

A CMS spokesperson said the agency wouldn’t comment on the program.

During the August press event, Kemp said the Biden administration’s attempt to stop the program in 2021 delayed its rollout and stymied enrollment. A federal court blocked the administration and allowed Georgia to proceed.

People familiar with the enrollment process said Pathways has been mired in design flaws and system failures. As of the end of May, 13,702 applications were waiting to be processed, according to state documents.

The program’s lengthy questionnaires and technical language are confusing, guidance is opaque, and tools to upload documents are tricky to navigate, according to interviews with health insurance enrollment specialists conducted for the Georgia Budget and Policy Institute.

“It’s not an easy, ‘Oh, I want to apply for Pathways,’” said Deanna Williams, who helps people enroll in insurance plans at Georgians for a Healthy Future, a consumer advocacy group. People generally learn about the program after being denied other Medicaid coverage, she said.

In the online application, people click through pages of questions before they’re shown a screen with information about Pathways, Williams said. Then they must check a box and sign a form saying they understand the program’s requirements.

Sometimes the Pathways application doesn’t pop up, and she must start over. The process to apply is “not smooth,” she said.

Data shows that people who don’t earn enough to qualify for free ACA plans but also make too much for Medicaid are disproportionately people of color. Pathways offers Medicaid coverage to adults earning up to the federal poverty level: $15,060 for an individual or $31,200 for a family of four.

Some people eligible for Pathways who work in retail or restaurants with fluctuating hours are nervous they can’t meet requirements every month, Williams said.

Many current enrollees don’t know how to upload documents, and the website sometimes stops working, said Jahan Becham, an employment specialist for Pathways at Amerigroup Community Care. Or people just forget.

Every month Becham gets a list of 200 to 300 enrollees who haven’t submitted their hours. “It is something new, and not many people are used to this,” Becham said.

“I would get reminders,” said Taylor, who attended the event for enrollees in August. “I just didn’t know how.”

In a June 2023 meeting with Georgia Medicaid staffers weeks before the program launched, federal officials questioned why the state wasn’t automatically verifying eligibility with existing data sources, according to meeting minutes KFF Health News obtained through a state open-records request. Georgia officials said they were unsure when they’d be able to simplify the verification process.

Many potential participants face improper denials, advocates said. Gibson, at the Georgia Legal Services Program, said not enough workers are trained to properly evaluate applications.

Fewer than 1 in 5 people who have their Pathways applications processed had been accepted into the program as of May, according to a KFF Health News analysis of state data. Roberts, with the state, said people were denied because they earned too much, didn’t meet requirements, or didn’t complete the paperwork.

A full-time graduate student was wrongly blocked from the program, and in February a state administrative judge ordered her case be reconsidered. In another case, a different judge ruled a 64-year-old woman who couldn’t work because she was her disabled husband’s full-time caregiver would not qualify for Pathways.

Despite the challenges, state records from May show no individuals were removed from the program since it launched for failing to meet work requirements.

Georgia’s experiment comes after a 2018 effort in Arkansas to implement work requirements on an existing Medicaid expansion population led to 18,000 people losing coverage, many of whom either met requirements or would have been exempted.

Taylor found out about Pathways when she applied for food stamps last year. It wasn’t until August that she learned she could submit her school schedule to meet the qualifying hours requirement. With a full Medicaid expansion, Taylor would have been eligible for health coverage without the extra effort. But, for her, it’s still worth it.

“It’s important to have health insurance,” said Taylor, who has been to the dentist several times and plans to visit a doctor. “I’m glad I have it.”